Just because you're terrified of gaining weight doesn't mean you don't want to be a mom.

If you’re pregnant and and feel like eating a whole jar of Nutella, you can always pull out the good old “eating for two” argument. But what if that’s the last thing you want to do? What if, as a pregnant woman with anorexia, you’d rather starve yourself ‘for two’ instead?

Just because a woman is anorexic—and is terrified of gaining weight—doesn’t mean she doesn’t want be a mom. “It’s not like I didn’t love my daughter, or didn’t want to take care of her when she was still in my womb. But because I had anorexia, I couldn’t make rational and healthy decisions while I was pregnant, both for myself and her,” recalls Maggie Bauman in the Daily Mail.

Bauman was one of the first people who spoke openly about dealing with anorexia while being pregnant. In 2009, she wrote a blog post for the now-defunct website momlogic.com, titled ‘Pregorexia: Starving for Two.’ After publishing the story, she received considerable backlash.

“My pregnancy felt like a nine month long battle,” wrote Bauman, who today works as an eating disorders specialist. “I was shocked by my growing ‘self’ and pushed back against every ounce I gained. Instead of [feeling a] sense of freedom to eat for two, I felt limited to starving for two.”

In the Netherlands, an estimated 5,500 young women battle anorexia every year and another 1,300 women join that group on an annual basis. At present, it’s unclear how many of these women become pregnant. We do know that one in 14 women in the UK deals with an eating disorder during the first three months of her pregnancy. In the US, about 30 percent of all women don’t gain enough weight when they’re expecting. An extreme obsession with weight while being pregnant is referred to as “pregorexia,” a mashup of the words “pregnant” and “anorexia.”

To be clear, pregorexia isn’t an official medical term, but a description that has been used mostly by the media. The word doesn’t refer to every woman who watches her weight while pregnant but is meant to describe an actual eating disorder. Most of the women who develop pregorexia have dealt with eating disorders in some way before they became pregnant.

“I’ve never met a woman who developed anorexia while she was pregnant,” says professor Myrian Vervaet, the head of the University Hospital Center for Eating Disorders in the town of Ghent, Belgium. “However, it could be noticed for the first time during pregnancy, for instance because [women] have refused to seek help before that time or weren’t aware of [the disease] themselves,” explains Vervaet in an interview with the Belgian newspaper Het Nieuwsblad.

"For young anorexic women who want to have children, the risk of becoming infertile often creates a lot of stress."

For women with a history of anorexia who’ve since overcome the illness, becoming pregnant can be a trigger that causes the eating disorder resurface, says Martie de Jong, a clinical psychologist who specializes in food- and eating disorders. “Even women who haven’t [dealt with] anorexia for some years can relapse while they’re pregnant.”

The disease’s full name, anorexia nervosa, literally means “neurotic loss of appetite.” But this is slightly misleading, as people who suffer from anorexia often don’t lose their appetite altogether—they just try to suppress it most of the time. They ignore pangs of hunger and strive to consume as few calories as possible. Patients are usually underweight (meaning they have a BMI lower than 17), compulsively think about food, and often workout to lose even more weight. Because of these symptoms, anorexia is considered a psychological condition, which negatively distorts the way people experience their body size and weight.

Among the physical effects of the disease are hair loss and osteoporosis (a weakening of the bones). A lack of estrogen can lead to amenorrhoea, meaning menstruation ceases. Some women with anorexia mistakenly believe that the absence of a period means there’s no risk of getting pregnant, so they don’t use birth control. However, during the first ovulation after amenorrhoea—especially while recovering from anorexia—it’s definitely possible, and it can lead to unplanned pregnancies. Though there is a risk of a permanent issues surrounding both menstruation and fertility after anorexia, most women will get their period again once they’re back at a healthy weight.

Plenty of women who have eating disorders also want to have a family. “I don’t see a difference between women with and women without an eating disorder when it comes to the desire to have children,” De Jong says. “This desire, however, can be a motivating force to deal with an eating disorder, so the mom is able to be a good example for her kid. And of course there’s often fear of gaining weight during the pregnancy. Women with an eating disorder are very afraid of that.”

“In case of young anorexic women, I’ve noticed that the risk of becoming infertile creates a lot of stress, and sometimes that’s actually the reason they want to fight their disease,” she says. “But there are so many different ways to experience pregnancy; it depends on the individual. Pregnancy can be a motivating force on the road to recovery, but could also be a setback—for example, for women who are in the middle of recovery and didn’t plan their pregnancy. In that case, a lot of fear comes with changes in their body and weight.”

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According to De Jong, women with anorexia usually have a need to be in control, and often struggle with a negative self image. The mother-to-be can start to feel like she’s losing control over her body and weight because of the mental changes that occur during pregnancy. “On a mental level, this causes added tension, stress and depression,” De Jong says. “ [Her] sense of self worth also decreases, because [she’s] no longer able to control [her body].”

Pregnancy can cause conflicting emotions for women with eating disorders. “I looked in the mirror a hundred times a day at this horrible belly,” an anonymous user writes in a blog on Proud2Bme, the biggest online support community for eating disorders in the Netherlands and Belgium. “On the other hand, it was beautiful, my child was growing in there […] I wanted my kid to have a healthy mom to lean on. Not a mom who faints right in front of him. I need to be able to take care of my child.”

The anonymous writer wants to be healthy for her baby, but also struggles with change. “I was kind of OK with the way things were. The number on the scale kept climbing, it didn’t stop. But the longer I was in therapy, the more I realized I had to eat for myself as well, and had to keep that up even after I gave birth.”

"I was so scared one of my vertebrae would break while I was nursing, because of the osteoporosis that was brought on by anorexia."

Women with anorexia often deny that they have an eating disorder. “They have a lot of difficulty admitting that they have an issue. They’re afraid to be stigmatized and also to lose control,” De Jong says. “And if their environment responds by saying things like ‘just start eating normally again, you’ll be fine,’ they feel misunderstood. People in the immediate environment of a patient with anorexia often don’t see the problem until it’s [noticeable]—and by then things have already gone wrong.”

Abigail Easter, a clinical psychologist who is connected to the British studies mentioned at the start of this article, says that a fear of being met with prejudice and stigmatization can cause women to keep eating disorders to themselves when they talk to doctors or other health care professionals.

When artist Liesbeth Raeven—who’s healthy today but has struggled with anorexia in the past—was trying to get pregnant, she realized that being afraid of prejudice amongst medical professionals is not unjustified. “You will never be completely free of it—even when it’s no longer a problem, you’ll never again have a completely carefree attitude towards food,” Raeven tells Tonic. Raeven and her twin sister Angelique are known internationally as L.A. Raeven; they create controversial “anorexia art” consisting of installations, performances, videos, and drawings.

Liesbeth Raeven as drawn by Angelique Raeven. Illustrations provided by the artists and via Ellen de Bruijne Projects.

Liesbeth Raeven says that this fear, however, can also be unfounded. As she was still waiting to get her monthly period again, health care professionals who were involved with her fertility treatment insisted that she remained too thin or that she was unhealthy. “After [having] an eating disorder for many years, my menstruation didn’t start up again, even though I’d maintained a healthy weight for years. They kept telling me that I had to gain more, even though my weight was totally fine.” Ultimately, she found a gynecologist was willing to help her against advice given by colleagues, who deemed her “too old” and believed all treatment options had been exhausted.

Raeven ended up having two healthy children, but she was still afraid of any residual effects of her anorexic past. “I was so scared one of my vertebrae would break while I was nursing, because of the osteoporosis that was brought on by anorexia and all those years I didn’t have my period. But luckily that didn’t happen.”

“If [a patient recovered and now has] a healthy weight, [refusing treatment] is worrisome,” De Jong says. “A history of anorexia can have lasting effects on fertility, but shouldn’t be a reason to refuse all treatment. Sometimes it could be assumed, incorrectly, that there’s still an active eating disorder, even though the woman in question has recovered. Perhaps in part because it’s so hard to acknowledge these disorders. But maybe there also isn’t enough understanding on the side of certain doctors and gynecologists.”

Ultimately, De Jong hopes that if a pregnant woman exhibits symptoms of anorexia, doctors or other medical professionals will recognize them. “I often see that eating disorders don’t get noticed, because the woman has never brought it up herself. It would be great if doctors could pick up on certain clues, so an eating disorder specialist can be notified in a timely fashion.”

Liesbeth Raeven as drawn by Angelique Raeven. Illustrations provided by the artists and via Ellen de Bruijne Projects.